CurrentBlue Cross Blue Shield - NevadaPolicy G-23002

Genetic Tests: Once per Lifetime, Reimbursement Policy

This reimbursement policy governs Anthem Medicare Advantage payment for specific germline genetic sequencing tests limited to once in a member's lifetime and applies to providers submitting claims for Anthem Medicare Advantage members.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyGenetic Tests: Once per Lifetime, Reimbursement Policy

Policy CodePolicy G-23002

Change TypeNo material change

Effective DateJan 1, 2024

Next Review Date

Key ActionServices must meet authorization and medical necessity guidelines and be billed using industry-standard codes; reimbursement for listed germline genetic sequencing tests is limited to once per member lifetime.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

once per lifetimelimitation on reimbursement for listed genetic sequencing procedures

not reimbursablereinterpretation/reanalysis

Anthem Medicare Advantageapplicability

01/01/2024policy effective date

Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyGenetic Tests: Once per Lifetime, Reimbursement Policy

Policy CodePolicy G-23002

Change TypeNo material change

Effective DateJan 1, 2024

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Reimbursement is allowed for specific genetic sequencing procedures listed in the Related Coding section only once during a member's lifetime.

The member's germline genotype is stable across a lifetime; repeat sequencing is not required for future interpretation of germline genotype.

Reinterpretation, reanalysis, or recategorization of variants based on previously obtained sequence data is not separately reimbursable.

Exceptions to the once-per-lifetime limitation may apply if provider, state, or federal contracts or requirements indicate otherwise.

Provider Actions and Billing Requirements

Note

Prior authorization, medical necessity, documentation, and billing requirements

Obtain prior authorization and ensure medical necessity are documented; bill using industry-standard CPT/HCPCS/revenue codes supported by the medical record. Reimbursement is limited to the listed genetic sequencing procedures once per member lifetime and reinterpretation/reanalysis of prior sequencing is not separately reimbursable — failure to follow authorization, medical necessity, or billing requirements may lead to claim denial, recoupment, or reimbursement adjustment.

Request and secure prior authorization when required and document clinical rationale demonstrating medical necessity for the procedure and diagnosis.
Use industry-standard CPT, HCPCS, and revenue codes on all claim submissions and ensure the billed codes are fully supported in the medical record or office notes.
Do not bill for reinterpretation/reanalysis of previously sequenced data as a separate reimbursable service; reimbursement is limited to the listed genetic sequencing procedures once per member lifetime.
Noncompliance with coding/billing or authorization/medical necessity requirements may result in payment recovery/recoupment, claim denial or rejection, or adjustment of reimbursement.

Definitions

Genotype / Germline

Genotype — definitionThe genotype is the individual organism's unique set of all the genes; germline refers to cells arising from the germ cells containing genetic code that may be passed to future generations

Also called hereditary/constitutionalGermline findings may also be referred to as hereditary or constitutional

Clinical relevanceGermline genotype is stable across a member's lifetime and forms the basis for once-per-lifetime sequencing limits

Sequencing

Sequencing — definitionDetermining the identity of each nucleotide (one of the four chemical bases) that makes up the DNA molecule to identify the genetic information carried

PurposeUsed to identify the kind of genetic information present in a particular DNA segment

Implication for policyBecause genotype is stable, repeat sequencing is not required for future interpretation

Variant

Variant — definitionA nucleotide deviation from a reference sequence of DNA; classified clinically (Pathogenic; Likely pathogenic; VUS; Likely benign; Benign)

Classification can changeAs evidence evolves, previous variant classifications may later require modification

Laboratory responsibilityEach laboratory assigns risk assessment to variants generally using an accepted classification scheme

OpenPayer

Genetic Tests: Once per Lifetime, Reimbursement Policy

Coverage Criteria

Coding and Limits

Provider Actions and Billing Requirements

Definitions